2013-11-14T06:51:42-06:00 2012-12-31 990 2012-01-01 420698265 ALLEN MEMORIAL HOSPITAL CORPORATION ALLE 3192353995 1825 LOGAN AVE WATERLOO IA 507031916 RENEE A RASMUSSEN 3192353544 2013-11-01 2012 2016-02-24 21:20:13Z PAMELA DELAGARDELLE 1825 LOGAN AVE WATERLOO IA 507031916 416460033 0 X WWW.ALLENHOSPITAL.ORG X 1938 IA IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE THROUGH HEALING, CARING AND TEACHING. 17 9 2293 365 228651 -169527 4076680 7130777 204453091 209306744 3713202 14601713 1601374 1666894 213844347 232706128 5824903 7919184 0 0 89039701 92528832 0 0 0 107263108 111127893 202127712 211575909 11716635 21130219 240687848 254744643 109217221 111201627 131470627 143543016 X THE MISSION OF ALLEN MEMORIAL HOSPITAL CORPORATION IS TO IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE THROUGH HEALING, CARING AND TEACHING. 0 0 168987279 7131001 210889674 HEALTH-CARE SERVICESALLEN MEMORIAL HOSPITAL CORPORATION IS AN IMPORTANT ELEMENT OF THE HEALTH-CARE DELIVERY SYSTEM THAT THE GREATER CEDAR VALLEY COMMUNITIES RELY ON EVERY DAY. IT IS COMMITTED TO PROVIDING QUALITY HEALTH-CARE AND TO USING ITS RESOURCES TO THE GREATEST COMMUNITY BENEFIT. ALLEN MEMORIAL HOSPTIAL CORPORATION PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES TO TREAT INDIVIDUALS WITH DISEASES, ILLNESS AND INJURIES WITH VARYING COMPLEXITIES. IT PROVIDES SERVICES TO IMPROVE THE HEALTH OF PATIENTS AND TO BETTER THEIR QUALITY OF LIFE. ALL SERVICES ARE PROVIDED REGARDLESS OF AN INDIVIDUAL'S RACE, CREED, SEX, NATIONALITY, HANDICAP, AGE OR ABILITY TO COMPENSATE FOR SERVICES RENDERED. THESE INCLUDE, BUT ARE NOT LIMITED TO, GENERAL ACUTE CARE, SURGERIES, HOME HEALTH, INTENSIVE CARE AND CRITICAL CARE, MENTAL HEALTH CARE, CARDIOLOGY, ONCOLOGY, REHABILITATION, BEHAVIORAL DISORDER PROGRAMS, MATERNAL/CHILD CARE, LABORATORY, PHARMACEUTICAL DRUGS, WOUND CARE, EMERGENCY SERVICES, OUTPATIENT CLINICS, CHECK-UPS AND RADIOLOGY. SOME OF THE SERVICES PROVIDED DO NOT GENERATE ENOUGH INCOME TO OFFSET THEIR COST. IN THE FISCAL PERIOD ENDED DECEMBER 31, 2012, ALLEN MEMORIAL HOSPITAL CORPORATION ADMITTED 10,516 PATIENTS WITHOUT NEWBORNS AND NICU AND 11,508 PATIENTS WITH NEWBORNS AND NICU, RESULTING IN A TOTAL OF 39,716 PATIENT DAYS WITHOUT NEWBORNS AND NICU, AND 42,355 PATIENT DAYS WITH NEWBORNS AND NICU. OUTPATIENT VISITS TOTALED 269,721 AND TOTAL OUTPATIENT SURGERY REGISTRATIONS FOR THE SAME PERIOD WERE 9631. THERE WERE ALSO 34,560 EMERGENCY ROOM VISITS AND 956 BABIES DELIVERED. 14676363 788183 CHARITY CARE, MEANS-TESTED PROGRAMS AND OTHER COMMUNITY BENEFITSCHARITY CARE AND MEANS-TESTED PROGRAMS: ALLEN MEMORIAL HOSPITAL CORPORATION PROVIDES CHARITY CARE AND OTHER MEANS-TESTED PROGRAMS WITH THE GOAL TO IMPROVE THE COMMUNITY'S OVERALL HEALTH AND ACCESS TO CARE. THIS INCLUDES HEALTH-CARE SERVICES REGARDLESS OF THE PATIENT'S INSURANCE COVERAGE OR FINANCIAL STATUS. CHARITY CARE AND PARTIAL TO FULL FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS ON A CASE-BY-CASE BASIS. CHARITY CARE WAS MADE AVAILABLE TO OVER 2,000 PEOPLE AT A VALUE OF $4,892,422 IN 2012. OFTEN TIMES, ALLEN MEMORIAL HOSPITAL CORPORATION RECEIVES PAYMENTS FROM PAYORS OR PATIENTS THAT ARE LESS THAN IT CHARGES FOR SERVICES. ALLEN MEMORIAL HOSPITAL CORPORATION PARTICIPATES IN MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH-CARE PROGRAMS. ALLEN MEMORIAL HOSPITAL CORPORATION'S NET COST OF PROVIDING CARE FOR WHICH IT RECEIVES PAYMENT BELOW ITS COST IS $4,997,847 FOR 2012. TOTAL CHARITY CARE AND MEANS-TESTED PROGRAMS REPORTED VALUE: $9,890,269.OTHER BENEFITS: ALLEN MEMORIAL HOSPITAL CORPORATION PROVIDES SEVERAL OTHER BENEFITS THAT ASSIST THE COMMUNITY. PROGRAMS MAY INCLUDE, BUT ARE NOT LIMITED TO, COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS SUCH AS PREVENTION AND HEALTH SCREENINGS; HEALTH PROFESSIONAL'S EDUCATION; SUBSIDIZED HEALTH SERVICES; RESEARCH, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. ALLEN MEMORIAL HOSPITAL CORPORATION COLLABORATES WITH OTHER HOSPITALS, CHURCHES, SCHOOLS, CHAMBERS OF COMMERCE AND DAYCARE CENTERS TO IMPROVE COMMUNITY HEALTH AND EXPAND ACCESS TO HEALTH CARE. ALLEN MEMORIAL HOSPITAL CORPORATION HAS DEDICATED STAFF TO ASSIST COMMUNITY BENEFIT EFFORTS. APPROXIMATELY 10,368 PERSONS WERE SERVED THROUGH THESE PROGRAMS. TOTAL OTHER BENEFITS REPORTED VALUE: $4,188,174. 183663642 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 192 0 1 2293 1 1 1 0 0 0 0 1 1 0 0 0 0 X 17 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IA X X RENEE RASMUSSEN SR VP FINANCECFO 3192353995 1825 LOGAN AVE WATERLOO IA 50703 MARK BALDWIN 1.00 1.00 X X 194 3574 0 BOB BUCKLEY 1.00 1.00 X 50 0 0 MICHAEL CHRISTIASON 1.00 1.00 X 313 177 0 DAVE HAPPEL 1.00 1.00 X 50 0 0 BETH HANSEN 1.00 1.00 X 50 0 0 BILAL KAAKI 40.00 1.00 X 720902 0 38773 LAWRENCE LIEBSCHER MD 1.00 1.00 X 50 11500 0 KATHY MCCOY 1.00 1.00 X 50 0 0 BEV SMITH 1.00 1.00 X 785 177 0 ROBERT SMITH 1.00 1.00 X 50 0 0 BETTY STEEGE 1.00 1.00 X 50 0 0 KALYANA SUNDARAM MD 1.00 1.00 X 649 0 0 KEVIN SWALLEY 1.00 1.00 X X 818 0 0 TOM TIBBITTS 40.00 1.00 X X 0 907099 25149 JEAN TRAINOR 1.00 1.00 X X 70 0 0 BISHOP STEVE ULLESTAD 1.00 1.00 X 445 0 0 MIKE WILLIAMS 1.00 1.00 X 418 14838 0 RENEE RASMUSSEN 40.00 1.00 X 301810 0 67808 RUSSELL ADAMS 40.00 0.00 X 0 346139 39656 JENNIFER FRIEDLY 40.00 0.00 X 161172 0 21884 TIM HORRIGAN MD 40.00 0.00 X 0 304393 37919 JUDITH RENAAS 40.00 0.00 X 280797 0 69957 STEVE SLESSOR 40.00 0.00 X 176620 0 23288 JAMES WATERBURY 40.00 1.00 X 227736 0 33675 CHRISTOPHER HILL 40.00 0.00 X 470738 0 21360 PAUL MCCAUGHEY 40.00 0.00 X 517851 0 32810 HIND MOUSSA 40.00 0.00 X 426572 0 14939 PUBLIO ORTIZ 40.00 0.00 X 427010 0 28868 ISLAM TAFISH 40.00 0.00 X 401013 0 21539 JOHN KNOX TO 1111 0.00 0.00 X 578376 0 26789 RICHARD SEIDLER TO 610 0.00 0.00 X 0 628499 258250 JEFFREY CRANDALL MD TO 511 0.00 0.00 X 0 212670 23435 JAY WILLSHER TO 910 0.00 0.00 X 0 323467 113701 4694639 2752533 899800 80 1 1 0 KNUTSON CONSTRUCTION SERVICES 2351 S SCOTT BLVD IOWA CITY IA 52240 CONSTRUCTION SERVICES 6323590 ARAMARK MANAGEMENT SERVICES LP 22506 NETWORK PLACE CHICAGO IL 60673 PERSONNEL 3777304 CEDAR VALLEY MEDICAL SPECIALISTS PO BOX 2758 WATERLOO IA 50704 MEDICAL SERVICES 3297665 LARSON CONSTRUCTION CO INC PO BOX 112 INDEPENDENCE IA 50644 CONSTRUCTION SERVICES 2089127 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUMS 1272281 20 3129 5987694 1112553 27401 7130777 NET PATIENT REVENUE 900099 156534798 156534798 PHARMACY REVENUE 446110 49414300 49205263 208867 170 RENTAL INCOME 531100 1694797 1694697 100 MANAGEMENT, IT AND SUPPORT SVCS 561000 1644939 1576515 68424 SUBS & JOINT VENTURES 900099 87905 68616 19289 -69995 -69995 209306744 1948709 1948709 11603 1528 10075 10075 10075 196181590 7926 183494262 42250 12687328 -34324 12653004 12653004 86372 66701 19671 19671 203382 149164 54218 54218 CAFETERIA/FOOD SVCS 722210 1008521 1008521 MISCELLANEOUS REVENUE 900099 532704 532704 PHARMACY REVENUE 446110 41705 41310 395 1582930 232706128 210592429 228651 14754271 X 7903309 7903309 15875 15875 2856574 2856574 858602 858602 70404157 64955601 5448556 2925455 2699055 226400 10442558 9634412 808146 5041486 4651327 390159 3731102 21870 3709232 935078 935078 407445 145355 262090 21623139 16325421 5297718 399604 13149 386455 5860870 5271066 589804 14143189 12246025 1897164 4136940 3289904 847036 271897 222655 49242 99575 64020 35555 3034265 3034265 12690128 12452313 237815 64038 64038 MEDICAL SUPPLIES 43554403 43540456 13947 MISCELLANEOUS EXPENSE 174987 146558 28429 BAD DEBT EXPENSE 1233 1233 211575909 183663642 27912267 0 3431635 6145478 11946275 4381261 1823270 1962915 23135969 25841528 5017238 3206197 6011290 5675057 765761 999110 225353437 120361640 100497693 104991797 80081908 96096467 102355 32349 4199562 1861853 3664892 3545631 10000 5000 240687848 254744643 19060424 20830901 28894 31805 91554 50049 5894584 6214230 84141765 84074642 109217221 111201627 X 125520236 139789258 4164387 1798280 1786004 1955478 131470627 143543016 240687848 254744643 X 21130219 -4692422 -4365408 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 84637772 6969458 10300929 2841422 183400 98883337 75776848 12020271 -907542 2013448 238357 84637772 62282606 6212189 8740976 1180548 278375 75776848 42620642 10459126 10425170 1016429 205903 62282606 59647961 2042078 -12929473 6014219 125705 42620642 0.96200 0.01980 0.01820 0 1 1 1284668 1284668 120210515 60533369 59677146 3212026 2677554 534472 90080647 52746452 37334195 10565581 4404265 6161316 104991797 ASBESTOS REMOVAL LIABILITY 4682439 DUE TO AFFILIATES 6814101 LONG-TERM RETENTION INCENTIVES 1124650 MISCELLANEOUS LIABILITY 810000 IOWA HEALTH SYSTEM NOTE PAYABLE 59557683 SELF-INSURANCE RESERVE 4500512 DEFINED BENEFIT RETIREMENT PLAN LIABILITY 5681431 HEALTH AND WELFARE BENEFITS RESERVE 903826 84074642 X 221984000 -4861896 2516837 -2345059 224329059 183400 8193669 8377069 232706128 200125000 150692 150692 199974308 183400 11418201 11601601 211575909 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IOWA HEALTH SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE HEALTH SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2009. THE HEALTH SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE HEALTH SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUES IN TEMPORARILY RESTRICTED FUND BALANCE 2,366,107. COST OF GOODS SOLD 149,164. RENTAL EXPENSES REPORTED AS OFFSET TO RENTAL INCOME 1,528. ROUNDING 38. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUES IN UNRESTRICTED FUND BALANCE 7,566,449. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 627,220. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 149,164. RENTAL EXPENSES REPORTED AS OFFSET TO RENTAL INCOME 1,528. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN UNRESTRICTED FUND BALANCE 10,790,952. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 627,220. ROUNDING 29. SCRUB SALES 53441 53441 43401 BOOK SALES 15073 15073 12996 7 17858 17858 10304 86372 86372 66701 66701 19671 1 1 X 1 X 1 X 1 1 1 0 1 1 4760651 4760651 0.02250 8953 20672848 15675001 4997847 0.02360 8953 25433499 15675001 9758498 0.04610 10004 1427238 142771 1284467 0.00610 364 91682 91682 0.00040 1077284 1077284 0.00510 29 3888199 1423767 2464432 0.01160 29 10368 6484403 1566538 4917865 0.02320 29 19321 31917902 17241539 14676363 0.06930 8 25 15496 15496 0.00010 1 1212 16540 16540 0.00010 1 30 807542 807542 0.00380 1 20 516 516 0.00000 11 1287 840094 840094 0.00400 0 3005909 0 73784025 71306056 2477969 X 1 1 1 ALLEN MEMORIAL HOSPITAL ORTHOPEDIC CO-MANAGEMENT COMPANY LLC MANAGE ORTHOPEDIC SERVICE LINE 0.20000 0.80000 1 1 ALLEN MEMORIAL HOSPITAL CORPORATION

1825 LOGAN AVENUE WATERLOO IA 50703

X X X ALLEN MEMORIAL HOSPITAL CORPORATION 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 11 ALLEN DIGESTIVE DISEASE CENTER-TWR PARK

125 EAST TOWER PARK DRIVE WATERLOO IA 50701

OUTPATIENT ONLY - DIGESTIVE DISEASE CENTER ALLEN WOMEN'S HEALTH CENTER

233 VOLD STREET WATERLOO IA 50703

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER PMP OCCUPATIONAL HEALTH

4612 PRAIRIE PARKWAY SUITE 102 CEDAR FALLS IA 50613

OUTPATIENT ONLY - OCCUPATIONAL HEALTH ALLEN WOMEN'S HEALTH CENTER

1600 1ST STREET E INDEPENDENCE IA 50644

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER BREAST BIOPSY SERVICES LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

PROVIDE BREAST BIOPSY SERVICES CEDAR VALLEY COMMUNITY HEALTHCARE LLC

999 HOME PLAZA SUITE 210B WATERLOO IA 50701

REGIONAL HEALTH INSURANCE POOL DIGITAL MAMOGRAPHY IMAGING SERVICES LLC

4250 GLASS ROAD NE SUITE 200 CEDAR RAPIDS IA 52402

DIGITAL MAMOGRAPHY IMAGING HEALTH ENTERPRISES VENTURES LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

INVESTMENT VEHICLE OWNING PARTS OF EACH OF THE CLINICAL JOINT VENTURES MRIOWA LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

PROVIDE MOBILE MRI SERVICE HEALTH ENTERPRISES OF IOWA

4250 GLASS ROAD NE SUITE 200 CEDAR RAPIDS IA 52402

MANAGEMENT COMPANY ALLEN OB-GYN

1015 S HACKETT ROAD SUITE 200 WATERLOO IA 50701

OUTPATIENT ONLY - WOMEN'S OB-GYN PART I, LINE 6A: ALLEN MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED AT WWW.UNITYPOINT.ORG. THIS SYSTEM-WIDE REPORT IS COMPLETED IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE HOSPITAL AND ITS REGIONAL AFFILIATES. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A. THE AMOUNTS ON LINES 7B-7C (UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS) ARE OBTAINED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO COST ACCOUNTING SYSTEM USE COST-TO-CHARGE RATIO. THE AMOUNTS FOR LINES 7E, F, H, AND I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND ARE BASED ON COST. THE AMOUNTS ON 7G ARE DERIVED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO A COST ACCOUNTING SYSTEM USE THE COST-TO-CHARGE RATIO. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1233. PART II: COMMUNITY BUILDING ACTIVITIES ARE ESSENTIAL ROLES FOR HEALTH-CARE ORGANIZATIONS IN THAT THEY ADDRESS MANY OF THE UNDERLYING DETERMINANTS OF HEALTH. RESEARCH HAS CONTINUALLY SHOWN THAT WHEN THE FACTORS INFLUENCING HEALTH ARE EXPLORED, HEALTH CARE ACTUALLY PLAYS THE SMALLEST ROLE PROPORTIONATELY. A REPORT IN THE JOURNAL OF AMERICAN MEDICAL ASSOCIATION AND THE CENTER FOR DISEASE CONTROL (MCGINNIS, 1996) SUGGESTS THAT THE FACTORS IMPACTING HEALTH ARE AS FOLLOWS: LIFESTYLE AND BEHAVIORS, 50%, ENVIRONMENT (HUMAN AND NATURAL), 20%, GENETICS AND HUMAN BIOLOGY, 20%, AND HEALTH CARE, 10%. COMMUNITY BUILDING ACTIVITIES HELP TO ADDRESS THE OTHER INDICATORS OUTSIDE OF THE ROLE TRADITIONALLY PLAYED BY HEALTH-CARE ORGANIZATIONS. THESE ACTIVITIES ARE ALMOST EXCLUSIVELY DONE IN SOME FORM OF PARTNERSHIP IN WHICH THE COMMUNITY OR OTHER ORGANIZATIONS ARE BETTER SUITED TO ADDRESS. HEALTH-CARE ORGANIZATIONS GENERALLY PROVIDE TIMELY AND SPECIFIC RESOURCES TO HELP THESE ISSUES. HEALTH-CARE ORGANIZATIONS CAN BE A RICH AND VALUABLE COMMUNITY RESOURCE IN WAYS NOT TYPICALLY CONSIDERED. OFTEN THE MOST EFFECTIVE WAY TO HELP IMPACT AND IMPROVE THE COMMUNITY HEALTH STATUS IS TO SUPPORT OTHER AGENCIES AND ORGANIZATIONS IN A VARIETY OF WAYS OUTSIDE OF HEALTH SERVICES. THIS IS OFTEN DONE THROUGH CASH OR IN-KIND SERVICES TO SUPPORT OTHER NON-PROFITS, DONATIONS OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES TO CERTAIN AGENCIES, OR THROUGH LEADERSHIP AND EDUCATIONAL EXPERTISE. THE HOSPITAL CONTRIBUTES FINANCIALLY TO A WIDE VARIETY OF COMMUNITY ORGANIZATIONS THAT ADDRESS THE BROADER NEEDS OF THE COMMUNITY. THESE DONATIONS ALLOW OTHER NON-PROFIT ORGANIZATIONS TO FULFILL THEIR MISSIONS TO IMPROVE THE WELL BEING OF THE COMMUNITY AND CONTRIBUTE TO ITS OVERALL HEALTH STATUS IN WAYS THAT MAY DIFFER FROM THE DIRECT SERVICES OF THE HOSPITAL ORGANIZATION AND MAXIMIZE THE RESOURCES THEY HAVE TO WORK WITH. THE HOSPITAL EMPLOYEES ARE ACTIVE IN EDUCATING PARTNERS ON A WIDE VARIETY OF HEALTH SUBJECTS THAT ADVANCE THEIR WORK. FURTHER, THE HOSPITAL EMPLOYEES ARE MEMBERS OF MANY NON-PROFIT BOARDS TO PROVIDE LEADERSHIP OR COLLABORATE TO ADDRESS COMPLEX HEALTH ISSUES. THESE TYPES OF ACTIVITIES SPEAK TO THE BREADTH AND CAPACITY THAT THE HOSPITAL HAS IN IMPACTING THE HEALTH STATUS OF THE COMMUNITY IN A COMPREHENSIVE AND INTENTIONAL APPROACH. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR ALLEN MEMORIAL HOSPITAL. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 8: AMOUNTS ON LINE 6 WERE CALCULATED USING IRS WORKSHEET B 'TOTAL MEDICARE ALLOWABLE COSTS.' THE MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORTS AND THEN REDUCED BY ANY AMOUNTS ALREADY CAPTURED IN COMMUNITY BENEFIT EXPENSE IN PART I ABOVE. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. PART VI, LINE 2: ALLEN MEMORIAL HOSPITAL CONTINUALLY WORKS WITH COMMUNITY PARTNERS IN WATERLOO, IOWA TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY. SPECIFICALLY, ALLEN MEMORIAL HOSPITAL IS A SPONSORING PARTNER OF THE COMMUNITY HEALTH ADVISORY BOARD, WHICH IS A COMMUNITY COLLABORATIVE CONVENED BY ALLEN HOSPITAL TO ASSESS, ADDRESS AND MONITOR THE HEALTH NEEDS OF BLACK HAWK COUNTY. THROUGH A PLANNED AND ORGANIZED EFFORT, THE COMMUNITY HEALTH ADVISORY BOARD DEVELOPS A HEALTH AGENDA BY IDENTIFYING SPECIFIC HEALTH PRIORITIES THAT ARE RELEVANT TO THE COMMUNITY. THE COMMUNITY HEALTH ADVISORY BOARD WORKS COLLECTIVELY TO ADDRESS THE PRIORITIES THROUGH LEVERAGING THE RESOURCES OF THE COMMUNITY. ALLEN MEMORIAL HOSPITAL, AS A SPONSORING AGENCY, ACTIVELY CONTRIBUTES TO THIS PROCESS AND ENGAGES IN THE IDENTIFIED PRIORITIES THAT MATCH ITS MISSION AND CAPACITY. THE COMMUNITY HEALTH ADVISORY BOARD CONVENES EIGHT MEETINGS ANNUALLY TO SEEK PUBLIC INPUT ON HEALTH INITIATIVES. ALLEN HOSPITAL IS ALSO A SPONSORING PARTNER IN TOGETHER FOR YOUTH. THIS COLLABORATIVE ALSO COMPLETES A COMMUNITY HEALTH ASSESSMENT. FROM THIS, PRIORITIES AND STRATEGIES HAVE BEEN IDENTIFIED. ALLEN HOSPITAL HAS ACTIVELY ENGAGED IN ADDRESSING AND MONITORING HEALTH ISSUES AND NEEDS AS A RESULT OF THIS PROCESS. ALLEN HOSPITAL ALSO PARTICIPATES AS PART OF THE UNITED WAY OF THE CEDAR VALLEY. THIS GROUP ACTIVELY ADDRESSES NEED AND STRATEGIES ASSOCIATED WITH HEALTH. MORE SPECIFICALLY, THIS GROUP OFTEN FOCUSES ON THE SOCIAL DETERMINANTS OF HEALTH AND HOW TO IMPACT THEM IN THE EFFORT TO RAISE THE COMMUNITY HEALTH STATUS. THIS WIDE BASED COLLABORATIVE PROVIDES OPPORTUNITIES FOR ALLEN HOSPITAL TO ENGAGE IN VARIOUS AREAS OF SERVICE TO THE COMMUNITY THAT MAY BE OUTSIDE OF ITS TYPICAL EXPERTISE BUT WITHIN ITS EXISTING RESOURCES. IN ADDITION TO THESE ORGANIZED COMMUNITY EFFORTS, ALLEN HOSPITAL CONTINUALLY MONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND THE RESOURCES IT CAN LEVERAGE TO ADDRESS THEM. INDIVIDUAL DEPARTMENTS OFTEN WORK TO IDENTIFY SPECIFIC NEEDS RELATED TO THEIR SERVICES AND THE POPULATION THEY IMPACT. PART VI, LINE 3: ALLEN MEMORIAL HOSPITAL PERFORMS THE FOLLOWING ACTIVITIES TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE AND FINANCIAL ASSISTANCE TO ALL PATIENTS: 1) PLACES SIGNAGE, INFORMATION, AND/OR BROCHURES IN APPROPRIATE AREAS OF THE PROVIDER (E.G., THE EMERGENCY DEPARTMENT, AND REGISTRATION AND CHECK-OUT/CASHIER AREAS) STATING THE PROVIDER/PHYSICIAN PRACTICE OFFERS CHARITY CARE AND DESCRIBES HOW TO OBTAIN MORE INFORMATION ABOUT FINANCIAL ASSISTANCE, 2) PLACES A NOTE ON THE HEALTH-CARE BILL AND STATEMENTS REGARDING HOW TO REQUEST INFORMATION ABOUT FINANCIAL ASSISTANCE, 3) DESIGNATES INDIVIDUALS WHO CAN EXPLAIN THE PROVIDER'S CHARITY CARE POLICY, AND 4) INSTRUCTS STAFF WHO INTERACT WITH PATIENTS TO DIRECT QUESTIONS REGARDING THE CHARITY CARE POLICY TO THE PROPER PROVIDER REPRESENTATIVE AND, 5) POSTS CHARITY CARE AND PATIENT-DISCOUNT INFORMATION ON THE HOSPITAL WEB SITE'S HOME PAGE AT WWW.ALLENHOSPITAL.ORG UNDER FINANCE. PART VI, LINE 4: ALLEN MEMORIAL HOSPITAL IS A 201-BED COMMUNITY HOSPITAL SERVING THE CEDAR VALLEY OF IOWA. ALLEN MEMORIAL HOSPITAL IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE.80% OF ALLEN MEMORIAL HOSPITAL'S MARKET RESIDENTS LIVE WITHIN THE IOWA COUNTIES OF BLACK HAWK, BREMER, BUCHANAN, FAYETTE, TAMA AND BUTLER. ALLEN MEMORIAL HOSPITAL ADMITS APPROXIMATELY 11,600 INPATIENTS AND CARES FOR 34,500 EMERGENCY PATIENTS PER YEAR. ALLEN MEMORIAL HOSPITAL CARES FOR MORE INPATIENTS, OUTPATIENTS, EMERGENCY PATIENTS AND CARDIAC PATIENTS THAN ANY OTHER HOSPITAL IN THE CEDAR VALLEY OF IOWA. THERE ARE 5 OTHER HOSPITALS WITHIN THE 6-COUNTY SERVICE AREA. MEDIAN HOUSEHOLD INCOMES RANGE FROM $42,108 TO $58,372 AND THE AVERAGE POVERTY RATE IS 11.5%.MORE THAN 50% OF ALLEN MEMORIAL HOSPITAL INPATIENTS ARE ELIGIBLE FOR MEDICARE OR MEDICAID. BLACK HAWK COUNTY, THE ONLY COUNTY IN THE SERVICE AREA WITH SIGNIFICANT MINORITY POPULATION, IS 87% CAUCASIAN AMERICAN AND BOSNIAN, 8% AFRICAN-AMERICAN, 4% HISPANIC AND 1% ALL OTHER MINORITY POPULATIONS. PART VI, LINE 5: THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. THE HOSPITAL SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF, AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. THE BOARD OF DIRECTORS OF THE HOSPITAL IS COMPOSED OF CIVIC LEADERS WHO RESIDE IN THE SERVICE AREA OF THE HOSPITAL. THE BOARD ACTIVELY DEBATES AND SETS POLICY AND STRATEGIC DIRECTION FOR THE HOSPITAL BUT DOES NOT GET INVOLVED IN ISSUES RELATED TO THE DIRECT OPERATIONS OF THE HOSPITAL. THE BOARD TAKES A BALANCED APPROACH WHEN ADDRESSING COMMUNITY AND BUSINESS/FINANCIAL CONCERNS. THE BOARD IS ALSO THE PRIMARY GROUP FOR DETERMINING THE USE OF HOSPITAL SURPLUS FUNDS, WHICH ARE ALL USED TO FURTHER OUR CHARITABLE PURPOSE. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM. INITIALLY FORMED IN 1995, IOWA HEALTH SYSTEM IS THE STATE'S FIRST AND LARGEST INTEGRATED HEALTH SYSTEM, SERVING NEARLY ONE OF EVERY THREE PATIENTS IN IOWA. THROUGH RELATIONSHIPS WITH 29 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND 280 PHYSICIAN CLINICS, IOWA HEALTH SYSTEM PROVIDES CARE THROUGHOUT IOWA AND ILLINOIS.IOWA HEALTH SYSTEM ENTITIES EMPLOY THE STATE'S LARGEST NONPROFIT WORKFORCE, WITH MORE THAN 24,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 4 MILLION PATIENT VISITS, IOWA HEALTH SYSTEM HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $2.7 BILLION, IOWA HEALTH SYSTEM IS THE FOURTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. IOWA HEALTH SYSTEM AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2012, IOWA HEALTH SYSTEM AND ITS AFFILIATES PROVIDED $421 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY IOWA HEALTH SYSTEM AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. REPORTS FILED WITH STATES PART VI, LINE 7 IA 1 AMERICAN HEART ASSOCIATION 460 N LINDBERGH BLVD ST LOUIS MO 63141 135613797 501(C)(3) 45320 PROGRAM SUPPORT GALLEGHER BLUEDORN UNI UNIVERSITY OF NORTHERN IA CEDAR FALLS IA 50613 426004333 501(C)(3) 48750 PROGRAM SUPPORT IOWA HEALTH PHYSICIANS 8101 BIRCHWOOD COURT SUITE N JOHNSTON IA 50131 421411630 501(C)(3) 4696841 PROGRAM SUPPORT MEMORIAL FOUNDATION OF ALLEN HOSPITAL 1825 LOGAN AVENUE WATERLOO IA 50703 421201138 501(C)(3) 3088604 PROGRAM SUPPORT 4 0 SCHOLARSHIPS 40 15875 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALLEN MEMORIAL HOSPITAL CORPORATION MONITORS THE USE OF GRANT FUNDS ACCORDING TO THE STANDARD FINANCIAL POLICIES OF THE ORGANIZATION AND AS REQUIRED BY THE GRANT OR GRANTOR. THE POLICIES AND PROTOCOLS OF THE FUNDING SOURCE ARE ENFORCED AND MONITORED BY THE ORGANIZATION AND REPORTED AS REQUIRED. X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 BILAL KAAKI 709549 0 0 0 11353 0 20245 0 18528 0 759675 0 0 0 TOM TIBBITTS 0 352970 0 49612 0 504517 0 12500 0 12649 0 932248 0 449963 RENEE RASMUSSEN 211425 0 67109 0 23276 0 44232 0 23576 0 369618 0 0 0 RUSSELL ADAMS 0 343217 0 0 0 2922 0 27329 0 12327 0 385795 0 0 JENNIFER FRIEDLY 142611 0 18561 0 0 0 4970 0 16914 0 183056 0 0 0 TIM HORRIGAN MD 0 252625 0 47748 0 4020 0 16412 0 21507 0 342312 0 0 JUDITH RENAAS 196168 0 60115 0 24514 0 69841 0 116 0 350754 0 0 0 STEVE SLESSOR 144192 0 32428 0 0 0 8977 0 14311 0 199908 0 0 0 JAMES WATERBURY 155032 0 48548 0 24156 0 11881 0 21794 0 261411 0 0 0 CHRISTOPHER HILL 434841 0 22847 0 13050 0 12500 0 8860 0 492098 0 0 0 PAUL MCCAUGHEY 473086 0 28499 0 16266 0 10271 0 22539 0 550661 0 0 0 HIND MOUSSA 423117 0 0 0 3455 0 9266 0 5673 0 441511 0 0 0 PUBLIO ORTIZ 426320 0 0 0 690 0 12500 0 16368 0 455878 0 0 0 ISLAM TAFISH 344095 0 0 0 56918 0 5000 0 16539 0 422552 0 0 0 JOHN KNOX TO 1111 0 0 114414 0 463962 0 16549 0 10240 0 605165 0 298980 0 RICHARD SEIDLER TO 610 0 480524 0 87666 0 60309 0 245587 0 12663 0 886749 0 0 JEFFREY CRANDALL MD TO 511 0 194821 0 16549 0 1300 0 9421 0 14014 0 236105 0 0 JAY WILLSHER TO 910 0 252108 0 39372 0 31987 0 88838 0 24863 0 437168 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS SPOUSES SOMETIMES ACCOMPANY BOARD MEMBERS AND/OR OFFICERS ON ORGANIZATIONAL ACTIVITIES, INCLUDING BOARD RELATED TRAVEL. THE ADDITIONAL COST ATTRIBUTABLE TO THE SPOUSE IS TREATED AS TAXABLE COMPENSATION TO THE BOARD MEMBER OR OFFICER AND REPORTED AS APPROPRIATE TO THE IRS. PART I, LINES 4A-B SEVERANCE PAYMENT: THE FOLLOWING INDIVIDUAL RECEIVED A SEVERANCE PAYMENT DURING THE YEAR THAT WAS INCLUDED IN THEIR TAXABLE INCOME: JOHN KNOX $164,981. SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN: THE FOLLOWING INDIVIDUALS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: RENEE RASMUSSEN $18,697, JUDITH RENAAS $44,841, AND RICHARD SEIDLER $223,629. ALLEN MEMORIAL HOSPITAL ORTHOPEDIC CO-MANAGEMENT COMPANY LLC COMMON BOARD MEMBER/OFFICER 29000 INVESTMENT 0 CEDAR VALLEY COMMUNITY HEALTHCARE LLC COMMON BOARD MEMBER/OFFICER 44000 INVESTMENT 0 CEDAR VALLEY MEDICAL SPECIALISTS PC COMMON BOARD MEMBER/SHAREHOLDER 4338000 RENT, MEDICAL SERVICES, LAUNDRY, PHONE, ETC. 0 IOWA HEALTH SYSTEM CONTRACTING SERVICES LC COMMON BOARD MEMBER/OFFICER 751081 PERFORMANCE OF SERVICES 0 KAREN KNOX FAMILY MEMBER OF OFFICER JOHN KNOX 24387 EMPLOYMENT 0 KIRK GROSS COMPANY COMMON BOARD MEMBER/OFFICER 640307 FURNITURE AND DESIGN SERVICES 0 NINA THOMAS FAMILY MEMBER OF BOARD MEMBER BEV SMITH 47906 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 2 ROBERT BUCKLEY; KATHY MCCOY; ROBERT SMITH; BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 ALLEN HEALTH SYSTEMS, INC., A TAX-EXEMPT IOWA NONPROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, ALLEN HEALTH SYSTEMS, INC., HAS THE POWER TO NOMINATE AND APPOINT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER, ALLEN HEALTH SYSTEMS, INC., HAS THE POWER TO APPROVE CHANGES IN ARTICLES AND BYLAWS, DISSOLUTIONS OR MERGER, AND APPOINT BOARD OF DIRECTORS. IN ADDITION, THE EXECUTIVE COMMITTEE WILL BE THE SAME AS ALLEN HEALTH SYSTEMS, INC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN NOVEMBER 2012 FOR THE FOLLOWING INDIVIDUALS: RENEE RASMUSSEN, JUDITH RENAAS, RICHARD SEIDLER, AND JAMES WATERBURY. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, HAS VOLUNTARILY ADOPTED MANY OF OUR INDUSTRY'S GOVERNANCE "BEST PRACTICES." IOWA HEALTH SYSTEM HAS DONE SO TO FURTHER ASSURE OUR STAKEHOLDERS THAT OUR GOVERNANCE AND MANAGEMENT IS CONDUCTED RESPONSIBLY AND WARRANTS THE TRUST YOU PLACE IN US. IN SEPTEMBER 2003, THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS VOLUNTARILY ADOPTED OVER 40 CHANGES TO ITS GOVERNANCE STRUCTURE TO BETTER COMPLY WITH GOVERNANCE BEST PRACTICES AND THE INTENT AND APPLICABLE REQUIREMENTS OF THE SARBANES-OXLEY ACT OF 2003. IN ADDITION, GOVERNANCE POLICIES AND RELATED INFORMATION HAS BEEN ADDED TO THE IOWA HEALTH SYSTEM WEBSITE, WWW.IHS.ORG, INCLUDING BUT NOT LIMITED TO: OVER 130 CORPORATE COMPLIANCE POLICIES, INCLUDING CHARITY CARE AND CONFLICTS OF INTEREST POLICIES; GOVERNANCE BEST PRACTICE POLICIES; THE IDENTIFICATION OF BOARD MEMBERS AND BOARD COMMITTEES; COMPENSATION FOR HOSPITAL CEO'S; AND FINANCIAL INFORMATION FOR THE PAST SEVEN YEARS. OTHER FEES FORM 990, PART IX, LINE 11G HEALTH-CARE PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 7,864,270. MANAGEMENT AND GENERAL EXPENSES 3,426,342. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,290,612. PURCHASED HOUSEKEEPING AND LAUNDRY : PROGRAM SERVICE EXPENSES 1,292,879. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,292,879. MISCELLANEOUS PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 7,168,272. MANAGEMENT AND GENERAL EXPENSES 1,871,376. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,039,648. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGES IN PENSION LIABILITY -4,365,408. ALLEN COLLEGE 1825 LOGAN AVENUE WATERLOO IA 50703 421351526 EDUCATE AND DEVELOP HEALTHCARE PROFESSIONALS IA 501(C)(3) 170(B)(1) (A)(II) ALLEN HEALTH SYSTEMS INC 0 ALLEN HEALTH SYSTEMS INC 1825 LOGAN AVENUE WATERLOO IA 50703 421201924 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 0 ALLEN MEMORIAL HOSPITAL CORPORATION 1825 LOGAN AVENUE WATERLOO IA 50703 420698265 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ALLEN HEALTH SYSTEMS INC 0 ANAMOSA AREA AMBULANCE SERVICE 101 GRANT WOOD DRIVE ANAMOSA IA 52205 421466284 PROVIDE AMBULANCE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'SJONES REGIONAL MEDICAL CENTER 0 CENTRAL IOWA HEALTH PROPERTIES CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 421233759 PROPERTY HOLDING COMPANY IA 501(C)(2) CENTRAL IOWA HEALTH SYSTEM 0 CENTRAL IOWA HEALTH SYSTEM 1200 PLEASANT STREET DES MOINES IA 50309 421189791 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 0 CENTRAL IOWA HOSPITAL CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 420680452 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) CENTRAL IOWA HEALTH SYSTEM 0 FINLEY TRI-STATES HEALTH GROUP INC 350 NORTH GRANDVIEW AVENUE DUBUQUE IA 52001 421307495 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 0 HNC SERVICES 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 270987243 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM 0 INTRUST 11333 AURORA AVENUE URBANDALE IA 50322 421477471 HOME HEALTH CARE IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM 0 IOWA HEALTH FOUNDATION 1415 WOODLAND AVE SUITE E-200 DES MOINES IA 50309 421467682 CHARITABLE FUNDRAISING IA 501(C)(3) 509(A)(3), TYPE III CENTRAL IOWA HEALTH SYSTEM 0 IOWA HEALTH SYSTEM 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 421435199 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE III 0 IOWA PHYSICIANS CLINIC MEDICAL 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